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I’ve been a bit remiss the last few days, in that the latest Health Wonk Review came out Thursday, and I’m just getting around to sharing it now.( Blog carnivals work best when contributors link back to the compilation.) But, better late than never, right?

In that spirit, and in the spirit of Thanksgiving, I invite you to check out Health Wonk Review: The Turkey Edition, hosted by David Harlow on his HealthBlawg. The big stories this time around are all about insurance coverage under the Patient Protection and Affordable Care Act, a.k.a., Obamacare, but there is also an interesting posts about “wrist slaps” given to pharmaceutical executives for allegedly violating drug-marketing laws.

My post at Forbes.com about the American Medical Association belatedly but predictably fighting the impending Medicare penalties for not meeting Meaningful Use makes the cut. I’m particularly proud of the line, “Ruthlessly Defending the Status Quo Since 1847. :)

Check it out, and for those of us here in the United States, have a happy Thanksgiving. I’ll see you after the long weekend.

While I’ve been busy writing a couple of stories on different topics, you’ve probably heard two pieces of news that will affect healthcare providers nationwide: the close of the first open enrollment period for Patient Protection and Affordable Care Act insurance exchanges and the Congressional “fix” (read “Band-Aid”) to the Medicare sustainable growth rate that statutorily delays the ICD-10 compliance deadline for another year, until October 2015.

The White House yesterday reported that 7.1 million people had signed up for health insurance through healthcare.gov or state-run exchanges, barely exceeding the Congressional Budget Office’s projection of 7 million. Independent tracking site ACAsignups.net says it’s more like 7.08 million, but still just above the goal. That site also tallies the following sign-ups as a result of the ACA:

4.71 million – 6.49 million through Medicaid/Children’s Health Insurance Program expansions;

2.5 million – 3.1 million “sub-26ers,” young adults whom the ACA allows to stay on their parents’ health insurance until age 26; and

1.8 million “woodworkers,” those who came out of the woodwork because they did not know before the Obamacare enrollment push that they were eligible for Medicaid or CHIP.

ACAsignups.net places the total range at 14.6 million – 22.1 million as of March 31, not counting the healthcare.gov numbers, though my math puts it at 15.38 million – 22.06 million. Add in the healthcare.gov sign-ups and you get about 22.5 million to nearly 29 million newly insured people. However — and this is a big however — we do not know how many of the beneficiaries are newly insured and how many were replacing previous coverage.

Personally, I bought a high-deductible, ACA-qualified health plan through an independent agent to replace a rather restrictive high-deductible plan that was grandfathered in, and should save about $70-$80 a month on premiums starting in May. The new insurer rejected me several years ago due to a pre-existing condition; the ACA assures that I can’t be denied for that reason anymore. I imagine there are millions in the same boat as I am.

The U.S. Census Bureau placed the number of uninsured for 2012 at about 48 million, or 15.7 percent of the population. (The same year, 198.8 million had private insurance.) Until we see new figures for uninsured Americans, we will still just have “gross” statistics, not a net figure to show if the insurance part of the ACA is working.

By the way, the ACA is about much more than insurance coverage, despite what the national media have focused on. I encourage you to read up on this before you say Obamacare is saving or ruining our country.

Now, as for the temporary SGR fix, the ICD-10 delay kind of came out of nowhere last week when it got slipped into the House version of the legislation, but the Senate adopted the same language — reportedly without debating ICD-10 at all — and President Obama today signed it into law. I’ve said before that ICD-10 and other transactional elements of healthcare stopped mattering to me as I watched my dad being mistreated in a hospital due to broken clinical processes in his last month of life. I still think this way. However, this sneaky move shows that the AMA, AHA and other groups more intent of protecting the status quo than fixing healthcare still have enormous sway in Washington.

It makes me wonder whether lobbyists haven’t already started pushing hard for Congress to delay the Medicare penalties for not achieving Meaningful Use that are due to kick in next year. Actually, I don’t wonder. I’m sure it’s happening.

All delaying real reform of a broken industry does is prolong the agony, and ensure that millions more people will be affected by errors and neglect in institutions that are supposed to “do no harm.” The status quo is not acceptable.

As you probably heard, CMS today released a 696-page final rule on accountable care organizations. I wrote a piece for InformationWeek Healthcare that should be posted no later than tomorrow morning, so I’m not going to rehash that. What I will do is show you the various reactions from many interest groups to the rule, particularly the ones that have an IT bent. Unfortunately, there haven’t been too many released so far, and none from the major health IT associations. Now, AMIA and CHIME are gearing up for their annual conferences next week and, let’s face it, the rule is 696 pages long, so I’ll update this page as statements come in.

For the official line, see CMS Admnistrator Don Berwick’s commentary in the New England Journal of Medicine. Notably, he mentions EHRs in the very first paragraph, in which he explains how he delivered accountable care as a Harvard pediatrician.

Rich Umbdenstock
President and CEO
American Hospital Association
October 20, 2011

Today’s rules represent the direction in which the hospital field is moving – toward better coordinated patient care across care settings. We commend CMS for listening to the concerns of America’s hospitals. The hospital field is actively working on ways to improve care delivery and the final accountable care organization rule provides hospitals a better path to do so.

In response to the concerns of the AHA and its hospital members, CMS made significant changes to the financial model, provided more flexibility in the assignment of beneficiaries and took a second look at the quality framework. We believe today’s menu of ACO options allows America’s hospitals to create new models of accountable care organizations on which the transformation of health care delivery is so dependent.

The AHA is also encouraged by the historic effort among several federal agencies to achieve the goal of better coordinated care. Specifically the antitrust agencies responded to hospital concerns and reversed their plan to require antitrust preapproval for every ACO applicant and instead provided guidance. We believe removing this barrier was essential to encouraging ACO participation.

Hospital and health system leaders welcome the concept of providing patient care in a more accountable, more coordinated way and know that they will be held increasingly at financial risk in improving outcomes for patients and becoming more efficient in the delivery of services. Hospitals already are engaged in private sector ACO initiatives and the final rule provides an additional avenue for the provision of accountable care.

The AHA strongly supports the goals and principles of the ACO program and delivery system reforms that improve patient care and quality while reducing costs. We will continue to work with CMS and other agencies to remove the substantial legal and regulatory barriers throughout the health care system to clinical integration that still remain.

I understand the American Medical Association had similar impressions, but I haven’t actually seen the AMA’s statement yet. However, the Advanced Medical Technology Association (AdvaMed), which stands to lose if expensive diagnostic tests are reduced, was disappointed:

AdvaMed Statement on

Final Accountable Care Organization Regulation

WASHINGTON, D.C. – Ann-Marie Lynch, executive vice president of the Advanced Medical Technology Association (AdvaMed), released the following statement regarding the Centers for Medicare and Medicaid Services (CMS) final rule on Accountable Care Organizations (ACOs):

“AdvaMed is concerned that CMS failed to address key issues in the final ACO rule that would have advanced patient care, ensured patient access to innovative treatments and technologies, and avoided incentives to stint on care.

“We are also concerned the rule does not address the very real danger of slowing the development of new treatments and cures. The failure to consider how innovative products play an important role in improving patient care threatens medical progress for current and future patients. Without certain design elements, the ACO program may have the effect of limiting treatment options and discouraging physicians from adopting new advancements in care.

“CMS failed to include or even discuss common-sense provisions to support continued medical progress, despite concerns expressed by the life science industry, patient groups, and members of Congress. CMS’ action runs counter to the President’s January 18 Executive Order directing agencies issuing regulations to seek to identify ways to promote innovation and undercuts the President’s goal of fostering a ‘national bioeconomy.’

“We are also disappointed that CMS rolled back rather than revamped the quality measures included in the draft rule. The final rule lacks sufficient measures of patient outcomes to assure quality of care. There are large areas of clinical practice not addressed at all – including cancer, severe arthritis, chronic pain and osteoporosis.

“This rule is a missed opportunity to ensure that the sweeping changes in payment policy established by the Affordable Care Act will support medical progress and assure that patients can receive the care most appropriate for their needs.”

The Association of American Medical Colleges was thrilled that med schools won’t be held to the same standards as everyone else:

AAMC Applauds Final ACO Rule Excluding Medical Education Payments

Washington, October 20, 2011— AAMC (Association of American Medical Colleges) President and CEO Darrell G. Kirch, M.D., issued the following statement today on the Medicare Shared Savings Program “Accountable Care Organizations”(ACO) Final Rule:

“The AAMC is pleased that the ACO final rule excludes indirect medical education payments from the methodology used to assess shared savings under the program. By not including these policy payments in the historical cost analysis, medical schools and teaching hospitals— institutions that often treat the sickest and most vulnerable patients—have a better opportunity to participate in the ACO initiative.

While we are still examining the details of the final rule, the AAMC has always been supportive of new models of care that put patients first and also leverage the benefits of institutions’ educational and research missions to reign in the unsustainable growth in health care costs. We look forward to working with our members, the Center for Medicare and Medicaid Innovation, and the Centers for Medicare and Medicaid Services to help identify ways to partner with the academic medicine community and institutions working to advance meaningful health system innovation.”

The Campaign for Better Care, a coalition of consumer groups interested in quality care for seniors, called the rule a “reasonable compromise”:

Consumer Groups Say New Accountable Care Organization Rule is a Reasonable Compromise, Urge All Parties to Get On-Board to Ensure Patients Will Soon Benefit from Better Coordinated, More Patient-Centered Care

Statement of Campaign for Better Care Leader Debra L. Ness

“The final rule on Accountable Care Organizations (ACOs), released by the U.S. Department of Health and Human Services today, has provisions that will both please and concern various parties. As advocates for consumers, particularly for our oldest and sickest patients who urgently need better-coordinated care, we applaud this effort to incentivize better primary care, increase coordination, and share accountability across providers. We are very pleased that this final rule will require ACOs to adhere to strong patient-centered criteria, use beneficiary experience of care measures to evaluate performance, and ensure full transparency, notification and choice for beneficiaries. These provisions are all essential to realizing the promise of successful ACOs, which patients in this country are counting on.

This new rule is not perfect, but it provides a path away from the broken, dysfunctional health care system we have today toward a system that offers higher quality, better coordinated and more patient-centered care.

We consider it most unfortunate that the provisions requiring beneficiary participation on ACO boards have been tempered. We urge the Department to closely monitor these provisions to ensure that consumers and beneficiaries are engaged in the design, governance and assessment of ACOs in their communities. We will be watching closely to assess whether ACOs operate in the public interest and reflect the needs and perspectives of the communities they serve. Consumers and patients hope and expect that these provisions will be strengthened down the road if needed.

In the end, we see this rule as a reasonable compromise. The Department was enormously responsive to the comments that were filed and in particular, to concerns raised by providers. It is time now for all parties to come together to create successful ACOs that deliver care that is truly patient-centered, that improves quality and care coordination, and that lowers costs. This new model of care deserves to be tested along with the numerous other innovations that have and will be promoted by the CMS Innovation Center. Patients and consumers have no time to waste.

The stakes are too high to ignore the promise that ACOs offer to improve care and bring us better value for our health care dollars. We must not let opponents of reform use any remaining differences to block the progress Americans so urgently need. Transformation is never easy, but the cost of failure to patients, families and the country is simply too high.”

AARP called the rule a “good first step” in improving quality and lowering Medicare costs:

AARP Statement on New HHS Programs Designed to Improve Coordination and Quality of Patient Care in Medicare

WASHINGTON—AARP Legislative Policy Director David Certner released a statement following today’s announcement that the Department of Health and Human Services (HHS) has issued a final rule introducing two new programs—the Medicare Shared Savings Program and the Advance Payment model—to help providers better coordinate patient care and use health care dollars more wisely through accountable care organizations (ACOs). Both programs create incentives for health care providers to work together to treat an individual patient across care settings – including doctors’ offices, hospitals, and long-term care facilities. Certner’s statement follows:

“Accountable care organizations have the potential to improve the quality and lower the cost of health care for all patients. By working across the spectrum of providers to ensure that patients get the right care at the right time and in the right setting, accountable care organizations have shown great promise in positively changing the way we deliver care.

“The programs announced today can benefit people in Medicare by encouraging providers to work together to better coordinate patient care, which can lead to fewer hospital readmissions and lower Medicare costs. AARP believes today’s announcement is a good first step and we welcome the chance to further review these programs.”

[A]nother resolution directs the AMA to tell the federal government that the EMR incentive program “should be made compliant with AMA principles by removing penalties for non-compliance and by providing inflation-adjusted funds to cover all costs of implementation and maintenance of EMR systems.”

It’s one thing to ask for more money to cover ongoing expenses. It’s another thing altogether to conclude that the government is not in compliance with the principles of a private organization. Talk about the tail wagging the dog.

In FierceEMR, I wrote:

Delegates also took issue with the Medicare e-prescribing bonus program that passed during the Bush administration and began this year. They said the requirement that physicians write 50 percent of their Medicare Part D prescriptions electronically was too onerous, and recommended that the threshold be lowered to 25 percent.

Not surprisingly, the posts drew several comments and e-mails.

AMA Board Chairman Joseph Heyman, M.D., someone who actually does understand—and use in his own practice—EMRs and information technology, left a detailed response on the BNET post, attempting to clarify the organization’s position on health IT. He’s right in saying that the AMA did come out in strong support of the stimulus. My criticism was about a few delegates who spoke out rather loudly about the stimulus.

Heyman also discusses the AMA’s online tools for physicians to learn about health IT, something I admittedly didn’t mention in my post, though it wasn’t completely relevant to my argument. I did interview Heyman at the meeting, and included some of his comments in a story I did in the July Physician Office Technology Report of Part B News. I’d like to extend an invitation to Heyman to do a podcast with me at some point in the future so we can discuss all of these issues, as well as his own practice’s successful experience with an EMR.

Another, anonymous, commenter suggested that other organizations, like the American Academy of Family Physicians has an agenda that “more closely aligns with the big winners of the last election cycle, and helped buy them a seat at the table.” Yeah, that would explain why some of the more conservative members of the AMA House of Delegates feel shunned. This person also says that “HIT providers”—vendors and consultants—are the real winners from the stimulus. That’s certainly a risk of the massive program.

The comments on the FierceEMR piece were more supportive of my argument. “Smart Doc” said: “To call this organization an anachronistic dinosaur would not give proper credence to how out of touch it is, not only with the public, but with physicians themselves. Like others of their ilk, they’re against government intervention except when it directly subsidizes them.”

I’m not sure if I’d go that far, but I’m certainly on record as saying the AMA really does not represent the interests of all physicians, as the organization claims to.

My favorite exchange, though, came from Jack Smyth, the very pragmatic president and CEO of ambulatory EMR vendor Spring Medical Systems. After the FierceEMR commentary appeared, he e-mailed me to clarify the rules for the Medicare e-prescribing bonus program that took effect this year:

You commented about the 50% rule for getting the eRx bonuses this year and next. In your statement you mentioned that unless a physician prescribes controlled substances, they should be able to qualify.

The way I understand it, if a doctor enters the prescription in the eRx system, it counts. Even if they have to print it out and sign it, because it’s a controlled substance, or even if the pharmacy doesn’t accept eRx and it has to be faxed to the pharmacy. There are several “G” codes that can be added to an office visit or prescription refill that allow the various scenarios to qualify for addition to the numerator of the equation.

I’m very proud of my subsequent response:

Thanks again for writing. I think you’re right about getting credit for entering it into an eRx system, regardless of whether it’s controlled or if the patient simply wants a printout. In that case, I have no idea why the AMA thinks 50% is too high. You’re either entering scripts electronically or you’re not, unless perhaps you’re Dr. House and you’ve stolen Wilson’s prescription pad.

I also asked Smyth for permission to post our exchange. He then responded: “I love your “Wilson’s prescription pad” comment! Yes you can use my email in your blog. I don’t have time to post responses on websites and I don’t like all of the banter (most of it useless) that a comment like this would create. I’ll let you do that.”

While I was on the air with news anchor Andrea Darlas of WGN-AM 720 in Chicago to discuss President Obama’s speech to the AMA, I promised this link to a story about a high-schooler in Washington state who correctly diagnosed herself in science class with Crohn’s disease after doctors were stumped for years. Folks, this is why we need clinical decision support.

Fellow blogger Lodewijk Bos of the Im-Patient blogcommented that he would like to see examples of the paranoia I observed at the AMA meeting. OK, but I have to link you to commentaries I wrote elsewhere, for FierceMobileHealthcare and FierceEMR. I humbly offer my “The audacity of ‘nope'” headline from the latter commentary for the Headline Hall of Fame.

Tonight, “Anonymous,” my biggest fan, left a comment asking where the proposed definition of meaningful use is. It’s right here, my friend. Actually, that page contains instructions on how to comment on the proposal. Scroll down for links to the preamble, a matrix of the proposed requirements and the CMS backgrounder on Medicare and Medicaid health IT provisions in the American Recovery and Reinvestment Act.

This is something I reported for the new FierceEMR last week: There’s a bill in the New Jersey legislature that would effectively ban the sale and use of health IT products that don’t carry CCHIT certification.

The story even drew a comment from CCHIT Chairman Mark Leavitt, who linked to a post on the commission’s blog. There, I learned from a commenter that the bill made it out of committee on a unanimous vote. That’s an ominous sign. If states start setting their own EMR rules, we’ll be left with 50 different systems of interoperability, few of which would actually interoperate with other. We will have wasted billions of taxpayer money on more silos.

If some of the paranoia about EMRs that I heard Sunday at the American Medical Association annual meeting really is representative of practicing physicians—and not just the protectionist Medical Establishment—this country is in trouble.

There’s some fairly significant news coming out of Washington tonight: A CNN Moneyreport via Yahoo! says that six key private-sector health industry groups have agreed to participate in the Obama administration’s effort to reform healthcare by pledging to take $2 trillion in costs out of the system over the next 10 years.

We’ll know for sure Monday when representatives from the six participating groups join President Obama at a press conference.

CNN reports that Obama will make reference to the AHIP-backed ad campaign that torpedoed reform efforts during the Clinton administration. “It is a recognition that the fictional television couple, Harry and Louise, who became the iconic faces of those who opposed health care reform in the ’90s, desperately need health care reform in 2009. And so does America,” Obama reportedly will say Monday.

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